2160 Exam #2 Ch. 15

The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate?

"Quitting smoking and keeping good control of your blood sugar levels are important." Smoking cessation and adequate glycemic control should be prioritized when teaching this client. Ankle edema should be assessed and followed up, but would not likely necessitate emergency care. Clients are not normally taught self-assessment of pulses, and quitting smoking and controlling blood glucose are more important than screening tests.

A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?

Assist the client to walk as soon and as often as possible. Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation. Raising the foot of the bed, vigorous massage, and active range of motion of the upper body may not prevent venous stasis.

When analyzing the nursing history recently taken on a client, which factor would alert the nurse to a significantly increased risk for chronic arterial insufficiency?

Cigarette smoking The use of any form of tobacco significantly increases a person's risk for chronic arterial insufficiency. The risk increases according to the length of time a person smokes and amount of tobacco smoked. Daily exercise would be a measure to reduce a person's risk for vascular disease. Family history of diabetes, hypertension, coronary heart disease, intermittent claudication, or elevated lipid levels would be important because these disorders tend to be heredity and cause damage to the blood vessels. Alcohol intake is unrelated to the development of chronic arterial insufficiency.

Assessment of a client's lower extremities reveals unilateral edema of the right extremity. Which of the following would be most appropriate for the nurse to do next?

Compare measurements of both extremities. If the legs appear asymmetric, the nurse should measure each leg and then compare the measurements to confirm the difference. The Allen's test is used to evaluate the patency of the radial or ulnar arteries. Checking for varicosities and palpating the femoral pulses are routine parts of the exam and unrelated to the assessment findings.

Which of the following assessment findings is most congruent with chronic arterial insufficiency?

Cool foot temperature and ulceration on the client's great toe Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency.

Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client?

Extent of tobacco use and exposure Tobacco use is one of the most significant risk factors for PAD and would supersede exercise tolerance, prevention of varicose veins, or dysrhythmias.

Walking contracts the calf muscles and forces blood away from the heart.

False

When assessing a client for possible varicose veins, which of the following would the nurse do?

Have the client stand for the exam When assessing for varicose veins, the nurse should have the client stand because the varicose veins may not be visible when the client is supine and not as pronounced when the client is sitting. Raising the client's leg would be inappropriate because this would promote venous return and emptying of the veins. Dorsiflexing the foot is used to assess the Homans' sign. The ankle-brachial index is used if the client has symptoms of arterial occlusion.

A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?

It filters harmful substances from the body. The lymphatic system's primary function is to drain excess fluid and plasma proteins, not capillary blood, from body tissues and return them to the venous system. The system contains lymph nodes that filter microorganism, foreign materials, dead blood cells, and abnormal cells and trap and destroy them. Antibodies and T lymphocytes are produced by the immune system.

If palpable, superficial inguinal nodes are expected to be:

Nontender, mobile, and 1 cm in diameter Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.

When assessing the lymph system of a 52-year-old patient, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate?

Normal finding Normally, the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less. Nonpalpable epitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence.

A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for?

Peripheral vascular problems The nurse should assess the client for peripheral vascular problems in both the legs. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. In case of an acute obstruction, the leg pain would persist even when the client stopped walking. Diabetes can cause pain as a result of diabetic neuropathy, which is unrelated to walking. Low calcium level may cause leg cramps but would not necessarily be related to walking.

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

Posterior tibial The posterior tibial pulse is located in the groove between the medial malleolus and the Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and the anterior iliac spine, just below the inguinal ligament. The popliteal pulse is often difficult to locate. It may be felt immediately lateral to the medial tendon. A light touch is important to avoid obliterating the dorsalis pedis pulse. It is normally about halfway up the foot immediately lateral to the extensor tendon of the great toe.

What should a nurse do if a posterior tibial pulse cannot be obtained on a client with edema of the feet?

Use a Doppler to assess for the presence of the pulse.

Which statement describes the correct technique by a nurse when performing the ankle-brachial pressure index test?

Use a blood pressure cuff that is 20% wider than the diameter of the client's limb. The correct technique involves using a blood pressure cuff that is 20% wider than the diameter of the limb being measured, inflating the cuff to no more than 20-30 mm Hg beyond when the last arterial signal was detected, slowly deflating the cuff so as to not miss the highest pressure. This first signal is the arterial pressure and is the number recorded, not the last sound heard.

The nurse documents a 2+ radial pulse. What assessment data indicated this result?

brisk, expected (normal) pulse

Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk?

• Lack of exercise • Overweight • Smoking Goals are not specific for peripheral vascular disease but instead focus on areas of risks for such disease, such as smoking, overweight, and lack of regular exercise. Family history and ethnicity are not modifiable risk factors.

A nurse is unable to palpate a client's radial and ulnar pulses. Which of the following would the nurse do next?

Palpate the brachial pulse. When unable to palpate a peripheral pulse, the pulse area immediately proximal to it should be palpated. In this case, the brachial pulse is indicated. Inability to palpate the client's pulses suggests arterial insufficiency.

The radial pulse is palpated over the lateral flexor surface.

True

During a health visit, a client says, "I know that arteries and veins are blood vessels, but what's the difference?" Which of the following would the nurse include in the response?

Arteries have thicker walls than veins. Arteries are blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries via a high-pressure system. Arterial walls are thick and strong and contain elastic fibers for stretching. Veins contain nearly 70% of the body's blood volume.